Office of the Professions
Delayed Registration - Personal Information

Personal Information
Note: Fields marked with an asterisk(* ) are required.
Do you have a Social Security Number?*
Social Security Number?

Date of Birth should be in MM/DD/YYYY format.

New York State DMV Driver or Non-Driver identification number; if you do not have a NYS DMV ID, leave this field blank.

Address Type*
Address Type

Licensee business address, phone, and email address are public information. If you indicate business for any of these items, that item will become public information at the time of licensure.

Phone Number Type
E-mail Type